A client is receiving isoniazid after being diagnosed with tuberculosis. Which information should the nurse include in the client's teaching plan?

Take vitamin B6 daily to prevent peripheral neuropathy.

Your urine and tears may turn orange.

Arrange for a hearing exam to monitor for hearing loss.

Wear sunscreen to prevent photosensitivity reactions.

Answer and Explanation

The Correct Answer is A

Choice A reason:
Isoniazid, an antitubercular medication, can cause peripheral neuropathy, a form of nerve damage characterized by numbness, tingling, or pain, particularly in the hands and feet. This side effect is due to the drug's interference with the normal metabolism of vitamin B6 (pyridoxine). Supplementation with vitamin B6 is recommended to prevent this complication. The normal daily recommended intake for vitamin B6 in adults ranges from 1.3 to 1.7 mg.

Choice B reason:
While it is true that isoniazid can cause discoloration of bodily fluids, turning urine and tears orange, this is not a harmful side effect and does not require intervention. It is, however, important to inform the client of this possibility to prevent alarm.

Choice C reason:
There is no evidence to suggest that routine hearing exams are necessary for clients taking isoniazid unless they have pre-existing hearing conditions or are taking other medications known to affect hearing. Therefore, this is not a standard part of the teaching plan for clients on isoniazid.

Choice D reason:
Photosensitivity reactions are not commonly associated with isoniazid use. While wearing sunscreen is generally good advice for skin protection, it is not specifically related to the administration of isoniazid and thus would not be the primary information to include in the teaching plan.

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Correct Answer is D

Explanation

Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.

Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.

Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.

Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.

A. Respiratory rate of 24/min. B. Weak, nonproductive cough. C. Pulse oximetry (SpO2) of 90%. D. Shortness of breath with activity.

Correct Answer is B

Explanation

Choice A reason:
A respiratory rate of 24/min is slightly elevated, which can be expected in a client with pneumonia due to the body's attempt to increase oxygen intake and carbon dioxide elimination. However, this rate does not directly indicate ineffective airway clearance.

Choice B reason:
A weak, nonproductive cough is a key indicator of ineffective airway clearance. In pneumonia, the presence of secretions in the airways is common, and an effective cough is necessary to clear these secretions. A weak cough that does not produce sputum suggests that the client is unable to clear their airways effectively, which can lead to impaired gas exchange and worsening of symptoms.

Choice C reason:
Pulse oximetry (SpO2) of 90% indicates that the client's oxygen saturation is below the normal range, which is typically between 95-100% for healthy individuals. While this finding is concerning and warrants intervention, it is a result of ineffective airway clearance rather than a direct indicator of it.

Choice D reason:
Shortness of breath with activity is common in clients with pneumonia and can result from various factors, including impaired gas exchange, decreased lung compliance, and increased work of breathing. While it may be associated with ineffective airway clearance, it is not as specific as a weak, nonproductive cough for indicating this particular problem.

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A client is receiving isoniazid after being diagnosed with tuberculosis. Which information should the nurse include in the client's teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment data for a 9-year-old reveals that she blurts out answers to questions before the question is completed, is unable to wait her turn, and persistently interrupts and intrudes in the conversations of others. The nurse would assess these behaviors as relating primarily to:

Correct Answer is D

Explanation

A nurse formulates the problem of ineffective airway clearance for a client who has pneumonia. Which assessment data best supports this problem?

Correct Answer is B

Explanation

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